Hepatitis C in Children - Pediatric Nursing - 1 of 2

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http://www.medscape.com/viewarticle/494498_1

From Pediatric Nursing

Hepatitis C in Children

Posted 12/20/2004

Sona Sehgal; L.

, a 3-year-old girl adopted from China 3 months ago, is brought to the

primary care office because her adoptive parents were notified that her

biological mother was recently found to be infected with hepatitis C.

has been apparently healthy, but her new parents want to know if she should

be tested for hepatitis C and, if found to be positive, is there a treatment

for this condition. The parents also expressed concern that hepatitis C

might be contagious and wondered if there were any precautions they should

take at home or that should be instituted at her daycare. They also want to

know if there are any long-term complications from hepatitis C requiring

ongoing monitoring and specialty care.

Significance of Hepatitis C Infection

Hepatitis C virus (HCV) was discovered in 1989 and was found to be the major

cause of post-transfusion non-A, non-B hepatitis. HCV infection is the most

common bloodborne pathogen in the United States (Center for Disease Control

and Prevention [CDC], 1998) with a yearly incidence in the 1980s of 230,000

cases. With the advent of methods to screen the national blood supply, the

yearly incidence has fallen to 25,000 cases annually. HCV is a ribonucleic

acid (RNA) virus of the flavivirus family. It has nine genotypes that vary

geographically, with genotype-I being most prevalent in the United States.

Genotyping of the virus is important because the response to treatment and

long-term complications of cirrhosis vary by genotype. Unfortunately, the

virus tends to mutate rapidly in the host making it difficult for the host's

immune system to eradicate the virus resulting in chronic infection (Hochman

& Balistreri, 2003). This mutation process also makes it difficult to

develop an effective vaccine.

Epidemiology

Prevalence

The prevalence of HCV in the general population of the United States is

estimated to be 1.8% (American Academy of Pediatrics [AAP], 2003). Although

HCV is a reportable disease many individuals with acute infections are

asymptomatic and, therefore, not diagnosed. Also, individuals at highest

risk for infection (i.e., injection drug users) may not readily seek health

care and diagnosis (Kim, 2002). According to the National Health and

Nutrition Examination Survey (NHANES), 3.9 million of the

non-institutionalized or incarcerated population has been infected with HCV,

and 74% of them have a chronic infection (Alter et al., 1999). In the

pediatric population under 12 years of age the seroprevalence is estimated

to be 0.2%, and in adolescents between 12 and 19 years of age the

seroprevalence is estimated to be 0.4% (AAP, 2003). Fifty to sixty percent

of children with HCV develop persistent infections even though they are

asymptomatic and do not have biochemical evidence of liver disease, but

limited data indicates less than 10% (as compared to 60%-70% of infected

adults) go on to develop chronic hepatitis and less than 5% develop

cirrhosis (AAP, 2003). The long-term effects of persistent low level

infection among children with HCV for 3, 4, and 5 decades is unknown at this

time. In adults with chronic hepatitis C there is a 1%-3% risk of

hepatocellular carcinoma development after 30 years of infection (El-Serag,

2003), but the risk for individuals exposed during childhood verses

adulthood are not known. Long-term cohort studies are needed to determine

the risk and associated factors for these serious complications.

Risk Factors

The major risk factor for virus acquisition is direct percutaneous exposure

to blood from a HCV-positive individual. Hepatitis C is much less contagious

than hepatitis B virus (HBV), with the risk of infection increasing

significantly with either repeated percutaneous exposure to infected blood

or infusion with large amounts of infected blood (U.S. Preventive Services

Task Force [uSPSTF], 2004). The average infection risk for HCV following a

single parental exposure to HCV-positive blood is 1.9% as compared to a 30%

infection risk following exposure to blood with HBV and a 0.3% risk of

infection with a single exposure to blood with human immunodeficiency virus

(HIV) (, 2003). Before 1990 blood transfusions or use of clotting

factor concentrates were the most common routes of spread. Because of the

exclusion of high-risk donors and testing of donated blood for hepatitis C

antibodies, the risk of HCV from a transfusion is now less than 1 in a

million transfused units of blood (AAP, 2003). All immune globulin products

and clotting factor concentrates released in the United States are now also

HCV negative.

Presently, the common risk factors for acquisition of HCV are parenteral

drug abuse (60%-90% of infections), high-risk sexual behavior (1%-10% of

infections), hemodialysis (10%-20 % of infections), and accidental exposure

in health workers (1%) (AAP, 2003). Contamination of medical equipment for

procedures in physician offices or specialty clinics resulting in outbreaks

of HCV among treated patients has been reported due to ineffective

sterilization procedures or reuse of syringes by medical personnel (CDC,

2003). Tattooing, body piercing, and use of shared razors have also been

implicated in HCV transmission (Borkowsky, 2002). Perinatal transmission of

HCV, although infrequent, is a significant cause of HCV in infants and young

children, but many children and adolescents diagnosed with HCV have no

identifiable source of infection (AAP, 2003).

In the United States the leading cause of HCV is the use of contaminated

needles and equipment for illegal intravenous drugs. The prevalence of HCV

infection among populations of injection drug users (IDUs) is estimated to

be between 30%-90%, increasing with duration and frequency of use of

parenteral drugs ( et al, 2002). Use of contaminated needles and

equipment also increases the risk of transmission of other blood-borne

pathogens, especially HIV. It is estimated there are over 200,000 people

with both HCV and HIV infections in the United States (, 2002). One

study found that 88% of HIV-positive youth who were IDUs were also infected

with HCV ( et al., 2002).

Perinatal HCV transmission

In pediatrics, maternal-fetal transmission accounts for most cases. The risk

to the fetus of acquiring HCV from an HCV RNA positive mother at the time of

birth is 5% (range, 0%-25%) versus a 95% risk of acquiring HBV from an

HBVsAg positive mother (Hochman & Balistreri, 2003; Schwimmer & Balistreri,

2000). Fetal monitoring during labor and prolonged rupture of the membranes

increase the risk of transmission of HCV. If the mother is co-infected with

HIV then the risk of the infant acquiring HCV goes up to 14% (range 5%-36%)

because HCV titers tend to be higher in women co-infected with HIV (Hochman

& Balistreri, 2003). Mothers with HCV can breastfeed, as high HCV titers in

breast milk have not been documented, but they should be counseled about its

presence (AAP, 2003).

Clinical Manifestations of Infection

The incubation period for HCV infection averages 6 to 12 weeks (AAP, 2003).

HCV RNA can usually be detected in serum 2 weeks after infection, and

anti-HCV antibodies appear 4-8 weeks later. All people with HCV antibodies

or HCV-RNA in their blood are considered to be infectious, but those

individuals with higher titers are more infectious. Acute infections are

usually clinically silent and symptoms, if present, indistinguishable from

symptoms found with hepatitis A or B infection. Only 20% of affected

individuals becoming jaundiced, and abnormalities in liver function tests

(elevations in the serum aminotransferase levels) are usually less

pronounced than found in people with acute hepatitis B infections (AAP,

2003). Infected children may complain of anorexia, malaise, fatigue, and

abdominal pain during the acute phase. The acute phase is followed by

resolution of symptoms although the serum aminotransferase levels may

continue to fluctuate.

Persistent infection occurs in 50%-60% of infected children even in the

absence of biochemical evidence of the liver disease (AAP, 2003). The

clinical sequelae for HCV in children varies. The majority of children with

chronic infections are asymptomatic, but a few (< 10%) develop chronic

hepatitis and < 5% go on to develop cirrhosis (see Figure 1).